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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700719
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:29:59 AM

Document Has Been Signed on 02/07/2023 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OPENDOOR SERVICESFACILITY NUMBER:
392700719
ADMINISTRATOR:NAKAWATASE, JOHNFACILITY TYPE:
775
ADDRESS:1129 ENTERPRISE STTELEPHONE:
(209) 475-1529
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 165CENSUS: 104DATE:
02/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Sherry Welker-LozaTIME COMPLETED:
11:55 AM
NARRATIVE
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On 2-7-23 at 10:21am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management on incidents reported on 2-1-23. LPA met with Program Director Sherry Welker-Loza and explained the purpose of the visit. LPA reviewed 2 incident reports with program director.

1. Incident reported on 2-1-23 stated resident1 (R1) arrived at day program on 1-31-23 with a visible black eye. Day program staff inquired with R! as to the reason for the black eye. According to incident report, R1 stated to day program staff that a staff member at the facility in which R1 resides struck R1. Day program reported incident to licensing department, ombudsman, and local law enforcement within regulatory time frames. Day program also conducted conversation with R1's place of residence.

2. Incident reported on 2-1-23 stated R2 struck R3 in the head and face on 1-31-23 while boarding a city bus transport. According to incident report, R3 was blocking entrance onto the bus when R2 struck R3. Day program reported incident to licensing department and local law enforcement within regulatory time frames, but did not report incident to Ombudsman per regulatory requirements.

Based on today's case management citations are cited per Title 22, Division 6. A civil penalty is issued in addition to citation due to a repeat violation with 12-month period. An exit interview was conducted with Sherry Welker-Loza and a copy of this report was given to Sherry. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2023 10:28 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/08/2023 06:58 AM


Created By: Michael Bilger On 02/07/2023 at 11:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OPENDOOR SERVICES
FACILITY NUMBER: 392700719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
CCR
82061(c)

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Reporting Requirements. (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the...ombudsman...corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...
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Licensee will conduct staff training on reporting requirements; regulation 82061 and submit proof of completed training to LPA by POC due date.

Licensee will regulation 82061 and submit a signed declaration of understanding to LPA by POC due date.
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This requirement was not met as evidenced by: Based on interview and record review, R2 and R3 were engaged in a physical altercation which was not reported to ombudsman. This posed a potential health, safety, and resident rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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